25 November 2020

Coronavirus in Romania: the third plateau

In stark contrast with the relatively quiet summer months here at home and in Europe, autumn has brought an avalanche of news, most of them bad, but some hopeful as well. The daily reported cases have skyrocketed in many parts of Europe, followed by increased hospitalizations and deaths, and by reports that in some cities, hospital staff are being asked to continue working despite testing positive. Governments have responded by gradually reintroducing restrictions, although not as harsh as the spring lockdowns.

In Romania the number of cases has also steadily increased throughout October, culminating in the first week of November, when almost each day another record was broken, and we surpassed 10.000 cases per day for the first time on November 6th. The following weeks this upward trend, which started in the second half of September, was finally interrupted: on the second week of the month the number of cases declined slightly, almost 1% compared to the first week, and in the third week it rose again, by a little over 3%. The number of people admitted to ICU is also rising steadily, surpassing 1000 patients on November 4th. The number of daily deaths peaked at 203 in the second week, on November 11th, when the weekly death count also climbed over 1.000 for the first time, but at least week-on-week growth slowed last week from 30% to only 7%.

I think there are many social factors fueling the current ‘second wave’. The initial panic in the spring has subsided, even though the infection risk is much higher with more carriers in the general population, and many view the pandemic as a nuisance preventing them from resuming a normal life. The relatively normal summer season has led people to become complacent and authorities have reacted slowly as cases started to build up again. Many companies have already ended work from home and called employees back into offices – as is apparent from mobility data – a major source of transmission. The strict initial lockdown has probably contributed to a sense that the government overreacted, not to mention how many are actively denying facts and spreading misinformation over Facebook.

As in other countries around the continent, the government is imposing increasing restrictions to try to control the spread, going as far as quarantining two major cities. The measures are less strict compared to March and April, and basically everyone is assuming there will be a more drastic lockdown after the Parliamentary elections in December. Although it is suspected that indoor gathering and private parties are causing a lot of infections, I do not have much confidence that imposing curfews and closing stores in the evening will improve the situation – in fact it does not seem to have helped much in the rest of Europe. Countries that have quickly and successfully stopped an emerging wave have acted swiftly and imposed extremely strict lockdowns – the more recent examples are Israel and Australia – so I do not expect these half-measures to have similar effects.

Daily new confirmed COVID-19 cases in November 2020 (Europe)
Daily new confirmed COVID-19 cases in November 2020 (Europe)

An interesting observation was that the European surge happened equally regardless of the level of mask wearing in different countries. Not a sign that masks are useless, but rather that they are a supplemental measure that cannot stop the pandemic on its own, and that infections can and do happen in places where people take off masks, such as during long office hours or when meeting friends and family indoors.

I do not have data to support this statement, but I think the leveling of cases we are seeing in November can be partially attributed to closing schools on October 20th. There is much debate around the topic whether small children are spreading the disease, and numerous studies supporting both possibilities. The problem with such studies is that children are rarely tested for infection, and are simply assumed to be safe because the lack of symptoms; on the other hand asymptomatic carriers are most definitely spreading the disease, so it logically follows that children can be spreaders too.

For now, it seems the situation in Romania is stabilizing at a dangerously high number of cases – another plateau from which we will have a tough time climbing back down. Compared to spring, the virus has spread to most of the country, the hospitals are filling up, and the medical staff is pushed to their limits. I fear that Christmas and New Years’ will contribute many more infections, despite restrictions and repeated warnings from government officials.

The fact of the matter is that top-down, government-imposed measures cannot be effective if the general population continues to either deny the existence of the virus, neglect to take the most basic precautions, or even actively undermine restrictions. According to some reports, there are people who recognize their symptoms, but instead of self-isolating awaiting confirmation, they are frantically running around to take care of business before they are put into quarantine – I am appalled by this level of recklessness! I think there is still a sense around here that it is the job of the government to solve everything wrong with society, a flawed mentality inherited from the decades of Communist rule. In a democracy however, we all need to take personal responsibility, and recognize that freedom does not come solely with rights, but with increased responsibilities as well.

Another factor I think may play a role is the amount of flexibility people have to adapt to these changing conditions. One good example is the earlier guidance to disinfect objects, as some experts thought the virus could be transmitted this way – this recommendation has since become mostly obsolete, as it becomes clear that airborne transmission is much more prevalent, but many people continue to disinfect while ignoring more effective measures. It is certainly hard to keep up with conflicting information, and journalists, experts and authorities are not sufficiently clear in their statements. We should keep in mind that with any new virus there are constantly new developments, and best practices can shift and change with time, as researchers find out more about the pathogen and the disease.

Daily new confirmed COVID-19 cases in November 2020 (world)
Daily new confirmed COVID-19 cases in November 2020 (world)

Amid these dire developments, there is room for some hope as well. Recent studies show that immunity should last at least six months. The mortality rates have gone down compared to the initial phase of the pandemic, owing to several reasons. Back then the testing capacity was limited and used mainly on people with symptoms, so it is possible the true number of infections was significantly larger in the spring, at least in the more affected regions. The first wave struck primarily the elderly, who develop severe cases of this disease and die more frequently, compared to the current even distribution among age groups. And in the months since doctors had time to refine medical procedures and to develop new ways to alleviate symptoms, while discarding others that have proven ineffective, such as hydroxychloroquine and remdesivir.

A specific issue contributing to more severe cases and larger number of deaths in Romania is that our population is usually averse to doctors. This means Romanians are more likely to have untreated conditions like heart disease and diabetes, and if they are happen to be infected with coronavirus, they will eventually go to the hospital in later stages of the disease, with more severe symptoms, when the treatment options become limited. But even here, the apparent mortality rates (a rough estimation dividing reported weekly deaths by cases from three weeks earlier) have declined from 7% in early May and 9% in early July to 3% at this current peak.

The hottest topic in recent weeks was vaccines, and this will likely capture public attention in the coming months. There are currently three vaccine candidates that announced high effectiveness and will be submitted for emergency approval in the US. There are however several caveats to these encouraging news. Results from Pfizer and Moderna have so far only been published as press releases, followed by some controversy as the CEO of Pfizer sold a portion of his shares in the company in the same day as the announcement. Even if results are genuine, it leaves the impression that he is getting rich off people’s suffering. Both Pfizer and Moderna vaccines are based on a new technique involving mRNA – safe under test conditions, but unproven in real-life context. Personally, I wonder whether this new technique is more likely to trigger autoimmune reactions: as human cells produce fragments of virus RNA, the immune system could start attacking those cells along with the virus. I would much prefer to see a longer duration trial, at least three to six months, to try to identify long term side-effects of these vaccines before proceeding with mass inoculation.

This concern aside, mass distribution will prove challenging either way: both mRNA vaccines require special storing conditions at low temperatures, compared to the Oxford vaccine based on a more traditional fabrication method. And all three need two doses a couple of weeks apart to trigger a strong immune response; this means double the doses to manufacture and distribute around the world, and it will take longer until the population can reach a sufficient level of immunity to stop the virus from spreading. I anticipate many communication problems, as some people could think a single dose makes them immune and thus skip the second inoculation, while others may stop respecting rules around social distancing and mask use in anticipation of ‘the cure’.

In the interest of managing the pandemic, Slovakia performed an interesting experiment by testing a large portion of the population (but leaving out children under nine years old) with rapid antigen tests to see if this can help reduce spread with less stringent lockdowns. The authorities asked positive cases to isolate and repeated the testing a week later to uncover possible false negatives. While cases have declined following this exercise, it is hard to name this as the deciding factor, as the country already had several restrictions in place in the weeks before. To me this seems like too much effort for too little benefit: this improves the detection rate of infections, but that does not stop the spread if people testing positive are not following instructions and isolating. Antigen testing has higher rates of failure; letting infected people who falsely tested negative circulate freely for a week until the next testing round would lead to secondary infections. To keep transmission in check, tests need to be performed regularly, and I doubt any country would be willing to repeat this massive logistic exercise every seven days. Rapid testing should definitely be available more widely as a quicker alternative to PCR tests and to provide early warning of growing clusters of infection, but it does not eliminate the need for discipline and distancing.

To finish off this lengthy article, I should mention a couple of reports about viral mutation. The first comes from Denmark and was caused by the virus infecting animals in their mink farms and returning to humans, a dangerous pathway that has led to the emergence of many virulent influenza strains. This one fortunately does not seem particularly concerning, because the mutation was reported back in March and so far has had no major impact. Another mutation of the virus, known as 614G, may have increased its transmission rate, making the pandemic more difficult to fight.

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